Forms


For new clients

The links below bring up forms that we will need to initiate counseling.

Consent for Treatment

This form tells my qualifications, explains your rights, and lays out our financial agreements. Please print, read, sign, and bring it to our first appointment.

Client History Form

This form ensures that I have relevant information about you, your personal history, and your family history—all information that helps us to plan and implement your treatment. Please print, fill out completely, and bring it to our first appointment.

HIPPA Privacy Policies

This form indicates legal requirements for confidentiality of information about you and your treatment, including limitations on who information may be shared with (e.g., insurers and other practitioners) and requirements for such sharing. Please print, read, sign, and bring it to our first appointment.

HCFA-1500

If your treatment will be covered by your insurance, and if I am a provider for your insurer, then please fill out the client data portions of this form so that I can file claims on your behalf. This form is not needed for self paying clients or those who pay in full and then personally file insurance reim­burse­ment claims. Please print, fill out, and bring it to our first appointment.

Telepsychology Consent Form

If we will be doing video or phone sessions, you must read this form, sign it physically (and then scan it) or sign electronically, and send it to me by email (obrienphd@comcast.net).

 

 

Email

Email address: beth@bethobrienphd.com (this link opens your email application)